NICE Quality Standards &
Performance Measures: QOF & COF
Tim Stokes
Consultant Clinical Adviser
General Practitioner, Ashby de la Zouch, Leicestershire
tim.stokes@nice.org.uk
Overview
• Performance measures
• Quality Standards
• Quality and Outcomes Framework (QOF)
– Overview of the NICE Managed QOF
• Experience to date (2009-2011)
• Commissioning Outcomes Framework (COF)
– Overview
Performance Measures
Performance Measures (1)
Institute of Medicine, US, 2002
• Patient perspectives
– patient assessment and satisfaction with their
access to and interactions with the care delivery
system
• Patient outcomes
– mortality, morbidity, and physical and mental
functioning
• Clinical quality measures
Performance Measures (2)
Institute of Medicine, US, 2002
• Clinical quality measures
– specific quantitative indicators
• to identify whether the care provided conforms to
established treatment goals and care processes for specific
clinical presentations
– consist of a descriptive statement or indicator
– Have a list of data elements that are necessary to
construct and/or report the measure
– Have detailed specifications that direct how the data
elements are to be collected
– may also include thresholds, audit standards, or
other benchmarks of performance
A performance measure – QOF
QOF
2012-13 Indicator wording
Points Threshold
ID
(%)
OST1 The practice can produce a register of
3
patients: 1. Aged 50-74 years with a
record of a fragility fracture after 1 April
2012 and a diagnosis of osteoporosis
confirmed on DXA scan, and 2. Aged 75
years and over with a record of a
fragility fracture after 1 April 2012
OST2 The percentage of patients aged
3
between 50 and 74 years, with a fragility
fracture, in whom osteoporosis is
confirmed on DXA scan, who are
currently treated with an appropriate
bone-sparing agent
-
30-60
Where do NICE Quality Standards fit
in?
What are NICE Quality Standards?
Quality Standard: set of specific, concise statements and
measures, developed from evidence-based guidance, that
act as markers of high-quality and cost-effective care or
services in a specific area.
NICE quality standards (17)
Registration
requirements
Proportion of
services
Standard of
services
Unsafe Substandard Adequate
Good
Excellent
How will quality standards be used?
• NHS White Paper Equity and Excellence:
Liberating the NHS
– “To achieve our ambition for world-class healthcare
outcomes, the service must be focused on outcomes
and the quality standards [developed by NICE] that
deliver them”
• Health and Social Care Bill
– Secretary of State and National Commissioning
Board have a duty to improve quality of services and
in discharging this duty they ‘must have regard’ to
NICE quality standards
– Commissioning guidance for clinical commissioning
groups will include NICE quality standards
Where quality standards fit in the
measurement pathway
Clinical
Guideline
Recommen
dations
Quality
Standard
statements
Quality
Standard
measures
- Audit
Criteria
Performance
measures for:
QOF
COF
QOF:
paying GPs to
perform …
Tim Hunkin
Under the Pier Show
Southwold , Suffolk, UK
The QOF
• Incentive scheme (2004)
– Open to all primary medical care providers
– rewards GP practices for implementing systematic
improvements in quality of care for patients
• Contains sets of clinical, organisational and patient
experience indicators
• Practices are assessed against the indicators
– score points according to their achievement
• Points generate income for the practices (P4P)
– £1bn ($1.5bn; €1.1bn) spend each year (15% of primary
medical care costs)
– £76 ($114; €84) per point (1000 points in total)
• 25% of GP practice income (2009-10 data)
NICE led QOF process (2009 – date)
• Independent body with transparent processes
– should be clear to all stakeholders why certain clinical areas
have been prioritised for development as QOF indicators
– Independent Advisory Committee
– Indicators published on NICE menu ahead of negotiations
• Considers cost effectiveness as well as clinical
effectiveness
– Net benefit approach used
• Indicators are piloted
• QOF as a vehicle for quality improvement
– existing indicators will be retired
– new indicators introduced when certain criteria are met
Who does what?
• NICE
– Manchester and London based
– Primary Care QOF Indicator Advisory
Committee
• The External Contractor
– Primary Care Group in the School of Health
and Population Sciences at the University of
Birmingham in collaboration with the York
Health Economics Consortium - YHEC
• The NHS Information Centre
• Key partners, including UK
devolved administrations
What is NICE’s role?
• √ Managing the process of developing and
reviewing the QOF clinical and health
improvement indicators
– Ensure consultation with individuals and stakeholder
groups
– Publish an annual “menu” of new, evidence-based
indicators
– Make recommendations about existing indicators
• X Deciding which indicators are included in
the QOF
– this will continue to be negotiated by NHS Employers
on behalf of the DH and the BMA GP Committee
How QOF indicators are developed
Characteristics of Performance
Measures: judgement or improvement?
Indicators for Judgement
Indicators for Improvement
Unambiguous interpretation
Variable interpretation possible
Unambiguous attribution
Ambiguity tolerable
Definitive marker of quality
Good data quality
Screening tool
Poor data quality tolerable
Good risk-adjustment
Partial risk-adjustment tolerable
Statistical reliability necessary
Statistical reliability preferred
Cross-sectional
Time trends
Used for punishment/reward
Used for learning / changing practice
For external use
Mainly for external use
Data for public use
Data for internal use
Stand-alone
Allowance for context possible
Risk of unintended consequences
Lower risk of unintended
consequences
Raleigh VS, Foot C. Getting the measure of quality opportunities and challenges. London: The King’s Fund, 2010
Key points in QOF process
NICE Quality Standards
Review of current QOF areas
Indicator development, piloting
and consultation
Review by QOF Advisory
Committee and publication
DH, GPC
and NHS
employers
Changes to QOF indicators
negotiated using the NICE menu
24 Months
NICE
Managed
Prioritisation of evidence-based
recommendations by QOF
Advisory Committee
NICE and the QOF: experience to
date (2009-11)
Overall (2009-2011)
42 new QOF indicators developed using
NICE process
29 (69%, 29/42) approved
by QOF AC
22 (76%, 22/29)
negotiated into QOF
2011/12 (9)
2012/13 (13)
Retirement (2009-11)
22 QOF indicators
have been
recommended for
retirement by the AC
Just under half (45%, 10/22)
have been retired from QOF by
the negotiators
Just under half (45%, 10/22) of the indicators
recommended for retirement are “paired”
indicators, where they relate to a health care
process that will still be required to occur for
another QOF indicator following any retirement of
the indicator (CHD5; CHD6; BP)
The future of QOF?
Moving from activity to outcomes
Paying for
Activity
Paying for
improved
health care
processes
- drug or nondrug
interventions
- Diagnosis
- Review
Paying for
improved
health
outcomes
- Intermediate
outcomes
- true health
outcomes
TO IMPROVE
THE
QUALITY OF
CARE
Types of QOF Indicators
Category
Number
(%)
QOF Points
(%)
Average points Points
achieved per
Achieved as %
practice
of Available
Health Outcome*
1 (1.2)
6 (0.9)
5.3
89.1%
Intermediate Outcome°
12 (14.0)
173 (24.8)
167.3
96.7%
Process measure directly 14 (16.3)
linked to Health
Outcomes+
Process measure
42 (48.8)
indirectly linked to Health
Outcomes≈
Disease Register
17 (19.8)
116 (16.6)
113.5
97.8%
331 (47.5)
311.5
94.1%
71 (10.2)
70.5
99.3%
Total
697 (100)
668.2
95.9%
86 (100)
* epilepsy – seizure free in past 12 months
° e.g., BP target; cholesterol target; HbA1c target
+delivery of drug therapy or other interventions that directly improve health outcomes;
≈ where the link between process and improvement in health outcomes is less direct (e.g. use of a
diagnostic test, clinical measurement, clinical review, advice)
The Commissioning Outcomes
Framework (COF)
Commissioning Outcomes
Framework (COF)
• The purpose of the Commissioning Outcomes
Framework will be to:
– drive local improvements in quality and outcomes for patients
– hold Clinical Commissioning Groups (CCGs) to account for
their progress in delivering these outcomes
• Include some proxy indicators of outcomes that are
good predictors of improvement
– ‘intermediate’ outcome indicators
– processes that are shown to have a strong link to outcomes
What is a COF indicator? (1)
• NICE Quality Standards
– Will form the basis of quality indicators that can be used to
measure the quality of specific aspects of clinical care achieved
through clinical commissioning groups
– The focus of NICE’s work will be measuring health care
processes that are linked to health outcomes
– COF indicators developed by NICE are intended to be
indicators for judgement
• Working definition:
• An indicator used to assess the quality of the services
commissioned locally by CCGs, that translate the NHS
Outcomes Framework, and other outcomes or proxies for
outcomes into indicators that are meaningful at local level.
What is a COF indicator? (2)
NHS
Commissioning
Board
Clinical
commissioning
groups
COF indicators:
• measure quality
• NHS CB to hold CCGs to account
•CCGs to hold providers to account
•“outcomes” bit of COF
Providers
Key points in COF process
NICE Quality Standard
Development of draft COF
indicators
NHS IC
COF Advisory Committee
- Prioritisation of draft COF
indicators
Indicator field testing
NHS
Commissio
ning Board
COF Advisory Committee
- Approval of final COF indicators
Recommends COF indicators
12 Months
NICE
Any questions?